Work Related Upper Limb Disorders€¦ · Work Related Upper Limb Disorders A rising tide of litigation has highlighted a growing problem of work related upper limb disorders (WRULDs),

RESEARCH PAPER 1998/5120 APRIL 1998

Work Related UpperLimb Disorders

A rising tide of litigation has highlighted a growingproblem of work related upper limb disorders(WRULDs), including the non-specific arm painpopularly known as RSI which is increasinglyprevalent amongst keyboard workers.

This paper discusses the variety of work related upperlimb disorders, the legislation and guidance in place toprotect the worker, and issues of compensation.

Graham Vidler

Social and General Statistics Section

HOUSE OF COMMONS LIBRARY

Alex Sleator

Donna Gore

Science and Environment section

Library Research Papers are compiled for the benefit of Members of Parliament and theirpersonal staff. Authors are available to discuss the contents of these papers with Membersand their staff but cannot advise members of the general public.

Recent Library Research Papers include:

List of Recent RPs

98/36 Unemployment by Constituency - February 1998 18.03.9898/37 Personal Tax Allowances & Reliefs 1998-99 18.03.9898/38 Cabinets, Committees and Elected Mayors 19.03.98

(revised edition)98/39 EMU: Views in the other EU Member States 23.03.9898/40 Economic Indicators 01.04.9898/41 The National Lottery Bill [HL] 1997/98 Bill 148 02.04.9898/42 Late Payment of Commercial Debts (Interest) Bill [HL] 02.04.98

1997/98 Bill 13298/43 The Crime and Disorder Bill [HL] [Bill 167 of 1997-98]: 06.04.98

Youth Justice, Criminal Procedures and Sentencing98/44 The Crime and Disorder Bill [HL], [Bill 167 of 1997-98]: 06.04.98

Anti-social neighbours, sex offenders, racially motivatedoffences and sentencing drug-dependent offenders

98/45 The 1998 Budget and Work Incentives Bill (forthcoming)98/46 Working Families Tax Credit and Family Credit 09.04.9898/47 Voting Systems - The Government's Proposals (revised edition) 09.04.9898/48 The Data Protection Bill [HL]: Bill 158 of 1997-98 17.04.9898/49 Unemployment by Constituency - March 1998 22.04.9898/50 Gibraltar, United Kingdom and Spain (forthcoming)

CONTENTS

I Variety and nature of Work Related Upper Limb Disorders 7

A. Introduction and terminology 7

B. History of WRULDs 8

C. Size of the problem 10

1. Prevalence 10

D. Range of Work Related Upper Limb Disorders 11

1. Specific WRULDs 12

2. Non-Specific Arm Pain 13

3. Occupational link 14

E. Management and prevention 15

F. Theories to explain diffuse WRULD and research 17

II Legislation and guidance 20

A. The Health and Safety at Work etc Act 1974 20

B. The 'Six-Pack' 20

1. The Management of Health and Safety at Work Regulations 21

2. Manual Handling Operations Regulations 22

3. Health and Safety (Display Screen Equipment) Regulations 23

4. Provision and use of Work Equipment Regulations (PUWER) 24

5. The Workplace (Health, Safety and Welfare) Regulations 25

6. Personal Protective Equipment (PPE) at Work Regulations 26

7. Updating the 'Six-Pack' Regulations 26

III Compensation 27

A. Fault versus No-Fault Compensation 27

B. Breach of statutory duty 28

C. Common Law Duty of Care 29

1. Individual cases 29

D. Social security benefits for prescribed diseases. 31

1. Industrial Injuries Advisory Council Review 32

2. Compensation Recovery Scheme 33

IV Appendix 1 34

Summary

Changes in work practices, in particular the introduction of the keyboard have co-incidedwith a growing problem of work related upper limb disorders (WRULDs). The termrepetitive strain injury (RSI) has been popularly applied to non-specific arm pain associatedwith repetitive movements and frequently implying an occupational cause.

This paper discusses the controversy surrounding the nature and cause of these conditions.There are problems in terminology. In medical circles the unwieldy term ‘work related upperlimb disorders’ is now preferred, whereas RSI remains in popular parlance. The range ofspecific and non-specific upper limb disorders which may be related to work is discussed.Physical and psychosocial factors which may promote WRULDs, together with preventativemeasures and management of the conditions are addressed, with particular emphasis on thenon-specific WRULDs.

Legislative control is affected through the Health and Safety at Work etc. Act 1974 and the‘six-pack’ regulations made under it. These reflect the EU Framework Directive on healthand safety and daughter directives.

Compensation for industrial injury may be sought through the civil courts for breach ofstatutory duty and/or breach of common law duty of care.1 In addition, compensation can beclaimed under the social security system.

1 The authors would like to thank Arabella Thorp who provided invaluable guidance about the breach of statutoryduty and common law duty of care.

Research Paper 98/51

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I Variety and nature of Work Related Upper Limb Disorders

A. Introduction and terminology

The term Repetitive Strain Injury, or RSI, has been popularly applied to a condition in whichrepetitive movements are associated with chronic incapacitating forearm pain and disability,and more specifically to occupational causation of arm pain. Lack of objective measurementsin a condition with diverse symptoms, few physical signs, and uncertain pathology is a majorproblem,2 and has been a matter of contention for a number of years. Evidence linking thecondition with repetitive movement is plentiful but largely circumstantial.

Confusion over the nature of the condition has been reflected in the change of nomenclatureand definition. A variety of terms have been used including overuse syndrome, chronicoccupational pain and cumulative trauma disorder. The most popular of these descriptiveterms is RSI. These terms have been criticised because they suggest a pathologicalmechanism that is usually not proved.

The term now preferred, “Work Related Upper Limb Disorders (WRULDs)”, does not definethe pathological mechanism, nor the diagnostic criteria but encompasses a range of conditionsaffecting the soft tissues and nerves of the hand, wrist, arm, elbow, shoulder and neck.Repetitive movements or sustained posture may result in a range of symptoms. These includepain, tingling, pins and needles, swelling, reduced ability to move the affected limb, stiffness andcramp. Though symptoms usually disappear with rest, they can lead to permanent disabilityparticularly in individuals with existing musculoskeletal disorders.

The term WRULD, although unwieldy, is technically more precise than RSI as the symptomsdescribed above can also arise from the non-repetitive handling of heavy loads. It may becaused by a single strain or trauma, not necessarily a repetitive or cumulative one.Furthermore, both psychological and social factors play an important role in the genesis andperpetuation of work related musculoskeletal disorders. The World Health Organisationconsiders the cause of such work related musculoskeletal disorders to be multifactorial.3

2 “Thermographic changes in keyboard operators with chronic forearm pain” SD Sharma et al. British MedicalJournal vol 314 11 January 1997

3 “ABC of work related disorders” 17August 1996 British Medical Journal vol 313


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Some well defined WRULDs (e.g. tenosynovitis and carpal tunnel syndrome)4 are recognisedby Government as prescribed in relation to specific occupations, thus acknowledging that thelink between work in that occupation and disease can reasonably be presumed. Whileregulations to guard against development of the variety of disorders covered by this term arein place, there is often difficulty in obtaining compensation, due to the problems in obtainingevidence of causation.

B. History of WRULDs

Recognition of pain and disability in relation to repetitive movement is not new. In 1713 theItalian physician Bernardino Ramazzini observed that clerks suffered from a condition causedby “incessant movement of the hand – always in the same direction”. Similarly, symptoms ofwriter’s cramp reported in the British civil service 160 years ago, were thought to be due tothe introduction of the steel nib.

In 1908 telegraphist’s cramp was included in the schedule of diseases that was covered by theBritish Workmen’s Compensation Act of 1906. Subsequently, within a period of three years60 per cent of the workforce were reporting symptoms of muscle weakness, cramp or painwhich they attributed to the new technology. As a result a committee was established whichreported the cause as being to “a nervous instability on behalf of the operator and to repeatedfatigue during the complicated movements required for sending messages”. Thepsychological aspects contributing to the condition were emphasised, and the term “nervousbreakdown” was coined.5

A dramatic increase in what became known as RSI occurred in Australia in the late 1970s andmid-1980s. A rise in upper limb disorders was also causing concern in Finland, Japan,Russia, the US and UK during the same period.6 The rates of reported upper extremitydisorders in the US tripled between 1986 and 1993.7 This rise coincided with the widespreadreplacement of typewriters with computer keyboards. It is paradoxical that introduction oflighter, easier machines should result in an increase in these work related problems. Due inpart to the Australian “epidemic” and the rising tide of litigation in the mid-to-late 1980s,opinions became polarised between those who saw a real occupational health problemdeveloping, and those who failed to see any real demonstrable medical condition. Somecommentators thought the problem was due to constitutional factors, exaggerated or extendedby emotional or psychological overlay, and possibly to involvement of the middle classes. Atthe far end of the spectrum it was considered to be mass hysteria with an element of joining

4 Tolley’s Health and Safety at Work Handbook 1998 010465 Journal of psychosomatic research 1994 vol 38 no6 p 493-498 Editorial “Repetitive Strain Injury”6 “Work related upper limb disorders – the situation today” Christopher Hayne, Chartered Physiotherapist of

Human Factors Occupational Safety and Risk Management, Croner Health and Safety Briefing 15 September1997 p5

7 The Lancet 1997; 349: 943-47 “Repetitive Strain Injuries”


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the bandwagon. In addition, the term RSI was more often used than repetitive strain disorder,in a move which reflected the rising numbers of employees embarking upon litigation. InAustralia, claims had grown to such a level that the government changed the compensationsystem so that symptoms associated with using keyboards were no longer compensated.8 Theincidence of the condition subsequently declined. There has been much debate in the medicalpress about the reality of the condition, and the relation to compensation:

A country’s compensation system has a great effect on the reporting and control of work relateddisorders. In Sweden there has been a substantial decrease in reported work related diseases,possibly due to an increased demand for evidence of work-relatedness before compensation isapproved. A generous compensation scheme can lead to patients becoming medicalised andlacking the motivation to attempt rehabilitation. However, a compensation scheme that facilitatesearly reporting of work related disorders allows early identification of hazards that mayconstitute a serious hazard to the workforce.9

Another commentator has said:

Symptoms of pain, numbness, swelling and weakness are frequent in those carrying outrepetitive actions of the upper arms, are related to their work, and are in the vast majority ofcases unrelated to psychiatric factors. However, those who are depressed, who are dissatisfiedwith their work, who believe they have been injured by activities at work and who are involvedin compensation are more likely to have persistent symptoms. Attitude and attributional factorsare more important than physical or mental illness in maintaining symptoms. Attitude to thework environment and psychological adjustment in those with severe or persistent symptoms ismore likely to explain the condition than close adherence to the medical model of illness.10

Some orthopaedic experts hold the opinion that RSI is not a valid pathological condition. TheBritish Orthopaedic Association undertook a review of the published literature and advisedthe Industrial Injuries Advisory Council (an independent statutory body) that, with theexception of writer’s cramp and tenosynovitis, there is insufficient conclusive evidence ofoccupational causation to prescribe any further types of “repetitive strain injuries”.11 On theother hand, ergonomists, physiotherapists, chiropractors, lawyers, Health and Safetyinspectors and trade unionists conclude that, in spite of problems of definition, thesedisorders comprise a growing phenomenon.

8 “ABC of work related disorders” Mats Hagberg, Professor of work and environmental physiology at the NationalInstitute for Working Life, Solna, Sweden 17August 1996 British Medical Journal vol 313

9 ibid10 Journal of psychosomatic research 1994 vol 38 no6 p 493-498 Stephen Tyrer Editorial “Repetitive Strain

Injury”11 “Occupational causes of disorders in the upper limb” N J Barton et al British Medical Journal vol 304, 1 February

1992 p309-311


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In recent years, a consensus towards recognition and management of the problem has beendeveloping:

There are signs of a more objective and rational approach to the subject of WRULDs and a basicagreement that, like any other occupational health problem, WRULDs need to be managed andthat preventive measures are preferable to sickness absence, reduced production and litigation.12

C. Size of the problem

In the wider context of WRULDs, problems are not limited to occupations traditionallyassociated with repetitive work such as keyboard workers. The following list of theindustries and groups of workers in the UK with a particularly high risk of WRULDsindicates the scale of the problem:13

• Electronics and telecommunications• Armed forces• Construction workers• Poultry and food processing• Garment and carpet manufacture• Domestic appliance manufacture• Packing and manufacture of small items eg biscuits• Cleaning operations involving the use of heavy polishers• Display screen equipment users• Supermarket checkout operators• Laboratory technicians

1. Prevalence

Studies by the Health & Safety Executive in 1990 and 1995-96 have attempted to ascertainthe true one year prevalence14 of work-related illness. The 1995-96 survey15 interviewedaround 1,500 people reporting a recent work-related illness in the quarterly Labour ForceSurvey about the nature and origin of their condition. Interviewees’ accounts were confirmedthrough GP assessment. By grossing up the results from this sample, the report attempts toestimate how many people in the population of Great Britain as a whole suffer from an illness

12 “Work related upper limb disorders – the situation today” Christopher Hayne, Chartered Physiotherapist ofHuman Factors Occupational Safety and Risk Management, Croner Health and Safety Briefing 15 September1997 p5

13 Adapted from “Work related upper limb disorders – the situation today” Christopher Hayne, CharteredPhysiotherapist of Human Factors Occupational Safety and Risk Management, Croner Health and Safety Briefing15 September 1997 p5 [no order of importance implied]

14 The number of people affected by a particular condition within a one year period.15 HSE Self-reported work-related illness in 1995


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related to their work. This section summarises their findings relating to musculoskeletaldisorders of the upper limbs and neck and vibration white finger.

Because of the survey’s small sample size, the estimates for the population as a whole mustbe treated with caution. National estimates are given as a single figure together with the lowerand upper ends of the 95% confidence range.16

302 respondents reported a musculoskeletal condition affecting their upper limbs or neck,17,18

suggesting that 506,000 people (confidence range 447,000-565,000) in Great Britain as awhole suffer from such a condition. This estimate suggests that slightly over one in a hundredpeople ever employed were affected. Prevalence was around 30% higher in women than inmen and, for both sexes, increased with age. 38% of respondents attributed their condition to“repetitive work”, 37% to “manual handling”, 23% to “posture” and 10% to “physicalwork”.19 Four occupational groups – the armed forces, construction workers, textileprocessing workers and other processing workers – have particular high rates of prevalence.The survey suggests that over two in every hundred people employed in one of theseoccupations is affected.

Nineteen people, all men, reported vibration white finger, suggesting that 36,000 (confidencerange 19,000-53,000) men in Great Britain suffer from this condition. Two-thirds ofrespondents reported difficulties in picking up and handling small objects because of theircondition. All respondents reported use of hand held power tools as the cause of theircondition.

D. Range of Work Related Upper Limb Disorders

All the tissues of the musculoskeletal system can be affected by occupationally relateddisorders.

Involvement of the joint can lead to inflammation and the degenerative changes of arthritis.Inflammation of the tissues around the joint can cause a range of conditions includingtenosynovitis (inflammation of the tendons and surrounding synovial sheaths)20 and bursitis(soft tissue inflammation). The muscles can suffer cramp, fatigue and inflammation. Nervescan become entrapped and inflamed and bones may be subject to stress fractures. Presenting

16 The range within which it can be said with 95% certainty that the true value lies.17 HSE Self-reported work-related illness in 1995 Table 70 page 15918 Carpal tunnel syndrome, frozen shoulder, tenosynovitis, RSI tennis elbow and golfer’s elbow.19 Respondents could cite more than one cause.20 Surrounding membrane that produces lubricating fluid


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symptoms include pain, tingling, pins and needles, swelling, reduced ability to move theaffected part, stiffness and cramp.

1. Specific WRULDs

Within the range of WRULDs a number of specific pathological disorders can be clearlyidentified.

The following table21 shows some of the more common specific identifiable WRULDs

Medical condition Symptoms Associated activitiesBursitis:Inflammation of the soft padof tissue between skin andbone, or bone and tendon.Can occur at the elbow(known as beat elbow) andshoulder (frozen shoulder).

Pain and swelling at the siteof the injury

Pressure at the elbow, repetitiveshoulder movements.Assembly line workers areparticularly liable to beat elbow.

Carpal tunnel syndrome:Pressure on the nerveswhich pass up the wrist.

Tingling, pain and numbnessin the thumb and fingers,especially at night.

Repetitive work with a bentwrist. Use of vibrating tools.Sometimes follows tenosynovitis

Cellulitis:Infection of the palm of thehand following repeatedbruising (called beat hand)

Pain and swelling of thepalm.

Use of hammer tools, likehammers and shovels, coupledwith abrasion from dust or dirt.

Epicondylitis:Inflammation of the areawhere bone and tendon arejoined. Called tennis elbowwhen it occurs at the elbow.

Pain and swelling at the siteof the injury.

Repetitive work, often fromstrenuous jobs like joinery,plastering, bricklaying.

Ganglion:A cyst at a joint or in atendon sheath. Usually onthe back of the hand orwrist.

Small, hard round swelling,usually painless.

Repetitive hand movement.

Osteo-arthritis:Damage to the jointsresulting in scarring at thejoint and the growth ofexcess bone.

Stiffness and aching in thespine and neck, and otherjoints.

Long-term overloading of thespine and other joints.

21 Adapted from Tolley’s Health and Safety at Work Handbook 1998 010/19


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Medical condition Symptoms Associated activitiesTendinitis:Inflammation of thetendons.

Pain, swelling, tendernessand redness of the hand,wrist, and/or forearm.Difficulty in using the hand.

Repetitive movements.

Tenosynovitis:Inflammation of the tendonsand surrounding tendonsheaths.

Aching, tenderness, swelling,extreme pain, difficulty inusing the hand.

Repetitive movements, oftennon-strenuous. Can be broughton by sudden increase inworkload or by introduction ofnew processes.

Tension of the neck orshoulder:Inflammation of the neckand shoulder muscles andtendons.

Localised pain in the neck orshoulders.

Having to maintain a rigidposture.

Trigger finger:Inflammation of tendonsand/or tendon sheaths of thefingers.

Inability to move fingerssmoothly, with or withoutpain (finger becomes“locked” in a bent position).

Repetitive movements. Having togrip too long, too tightly, or toofrequently.

A further disorder affects the blood supply to one or more fingers:

Medical condition Symptoms Associated activitiesVibration white finger:Vascular spasm (constrictionof small blood vessels) andneurological changes infingers and forearm;extensive changes called“hand-arm vibrationsyndrome”.

Painful white fingersparticularly in cold weather(Raynaud’s phenomenon).Also tingling, numbness, lossof manual dexterity.

Use of power hand held vibrationtools, such as chain saws,compressed air pneumatichammers and rotary tools.

2. Non-Specific Arm Pain

There remains a proportion of WRULDs which comprise non-specific use-related pain andfatigue in the forearms associated with non-specific physical signs such as diffuse tenderness.The term non-specific arm pain is employed for these sufferers, and some still refer to this asRSI. Workers as diverse as keyboard operators, hairdressers, packers, assembly workers andpianists can be affected. Though symptoms usually disappear with rest, they can lead topermanent disability particularly in individuals with existing musculoskeletal disorders.


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3. Occupational link

It is important to remember that most conditions that can be categorised as WRULDs alsooccur without any connection to occupation. They can be the result of leisure, sport anddomestic activities, and the specific cause can often be difficult to confirm. In addition itmay be that the presenting “occupational” complaint is the first indication of any one of anumber of chronic rheumatic conditions which are common in the general population. Forexample, isolated carpal tunnel syndrome22 can be a presenting feature of rheumatoidarthritis, hypothyroidism,23 and systemic lupus erythematosis,24 as well as being ofoccupational or idiopathic25 origin.

Because the rheumatic diseases are common, it is likely that some employees will be able toattribute their symptoms to these conditions. Only up to 20 per cent of musculoskeletaldisorders which affect the neck, and upper limbs can be satisfactorily linked to workactivities.26

Ergonomic factors, or conditions associated with the nature of the job or work, haveparticular impact in the generation of WRULDs. Symptoms may be associated withrepetitive movements of low impact, sustained posture, repeated heavy impact loading (forexample in coalface workers, farmers and less obviously in professional dancers).

Some examples include:27

• working with the hands at or above shoulder level may be a factor in generationof shoulder tendinitis in assembly workers

• neck flexion while working at a visual display unit (VDU) may be associatedwith non-specific neck and shoulder symptoms – neck pain is more prevalentamongst workers who flex the neck more acutely.

• Use of a computer mouse may result in adoption of new postures resulting in acombination of symptoms at the wrist and shoulder. Work tasks of long durationwith flexed and, to some extend extended wrists, have been reported as riskfactors for carpal tunnel syndrome.

22 pain and tingling in the hand and arm due to pressure on the median nerve at the wrist23 underactive thyroid24 A chronic inflammatory disease of connective tissue25 arising spontaneously, of no known origin26 “Work related upper limb disorders – the situation today” Croner Health and Safety Briefing 15 September 1997

p527 “Neck and arm disorders” Mats. Hagburg British Medical Journal vol 313, 17 August 1996


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It has become apparent that there is often no simple explanation for the onset of WRULDsymptoms. There may be a number of contributory factors which interact. While physicalfactors such as excessive stress on joints, poor posture and repetitive tasks with insufficientrest periods may interact to cause symptoms, in some individuals psychosocial factors mayalso play a part. Peer pressure or workers incentive schemes, for example, may lead a workerto attempt to complete a task quickly with insufficient rest breaks. Lack of knowledge mayalso be a factor – it is essential that workers are well informed and can therefore guardagainst these problems.

Some of the factors which may interact to produce symptoms of WRULDs are detailedbelow.28

Physical factors Psychosocial factorsSystems of work/poor postures Job demandsStressful upper limb postures Job complexityRepetitive actions and short cycle tasks Job securityExcessive joint loading Perceived threat of technological advancesStatic muscle work Interpersonal relationshipsInadequate rest pauses Lack of knowledgeNoise, light, heat etc. Work incentive schemesIndividual susceptibility Peer pressurePre-existing medical conditions Desire to conform

E. Management and prevention

Following increased recognition of the problem of WRULDs, including non-specific armpain, management and prevention are now being addressed.

The clinical course of non-specific arm pain may be considered in three stages:29

Stage 1 During this stage most patients experience aching and weakness during thework activity, but improve during days off work. There are no physicalsigns and no interference with work. This stage may last several weeks ormonths.

28 “Work related upper limb disorders – the situation today” Croner Health and Safety Briefing 15 September 1997p.5

29 The Lancet vol 349 March 29 1997 “Repetitive strain injuries”


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Stage 2 Symptoms begin more quickly, persist for longer, and interfere with work.Physical signs may be present, and sleep may be disturbed. The stage maylast for some months.

Stage 3 Symptoms are present even at rest. Non-occupational activities and sleepare disturbed, and the patient is unable to carry out light duties. This stagemay persist for months or years, and the outlook is generally poor.

There is a consensus of opinion that early treatment reduces ultimate disability, and thereforeearly reporting and intervention should be encouraged. WRULDs with a specific diagnosismay require specific intervention, including surgery in some cases. However, the followinggeneral principles of management apply, especially for the non-specific WRULDs.

The most effective preventative measure, which is also a part of early treatment of adeveloping WRULD, is to reduce or eliminate exposure to the ergonomic hazards associatedwith the disorder. This can be achieved by regular rest breaks, job rotation, restricted duty ortemporary job transfer. Complete removal from the work environment should be reserved forthose with severe disorders or when job modifications or other work assignments are notavailable.

Any necessary ergonomic modifications to the workstation should also be carried out earlyon and ideally be replicated on all workstations as a preventative measure. Indeed, ergonomicfactors should be considered in engineering design of equipment.

The focus of medical intervention is to rest the part with symptoms and to reduce soft-tissueinflammation. Cold treatment can reduce symptoms associated with tendon-related disorders,and anti-inflammatory drugs30 (aspirin and other non-steroidal anti-inflammatory agents) canreduce soft-tissue inflammation. Splinting the affected part is worthwhile in somecircumstances, but care must be taken that their use does not lead to muscle wastage.Physiotherapy can be useful in treatment and rehabilitation. Relaxation and exercises, heatapplication, massage and ultrasound treatment can all be helpful. Stretching exercises shouldinitially be done under supervision to ensure they are correctly performed, and do notaggravate the injury.

For most people ergonomic interventions and conservative treatment31 will provide relief. Ifconservative measures fail local injection of anaesthetic agent and a corticosteroid may beindicated in some cases,32 and in a few surgery will be required. For example, in carpal tunnelsyndrome, where conservative treatment fails, surgery may sometimes be necessary to relievepressure on the median nerve.

30 “Repetitive Strain Injuries” The Lancet 29 March 199731 Treatment aimed at preventing the condition from becoming worse, in the expectation that the natural healing will

occur, and no drastic treatment will be necessary32 “Repetitive Strain Injuries” The Lancet 29 March 1997


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Some patients with non-specific WRULDs do, however, develop an intractable problem. Painand disability may subside when the limb is rested only to return when the patient resumesnormal work activities. These individuals may have to change their work methods, forexample by dictating work for others to type up, or by using voice activated word processors.

The general principles of managing hand and arm pain in keyboard operators can besummarised:33

• Exclude clear pathological causes such as carpal tunnel syndrome• Reassure patient that the condition is curable• Keep patient at work if possible but away from keyboard work if necessary• Monitor patient’s progress with regular follow up• Explore psychological profile, including attitudes to work and support from

management and colleagues• Liase with patient’s workplace, if possible with an occupational physician or

nurse• Ensure that workstation ergonomics have been evaluated and are satisfactory and

that patient has been taught to use the equipment properly and has the rightglasses

• Enquire about variation of work tasks, work or job rotation• Hospital admission is rarely needed, physiotherapy may be appropriate for some• Those few patients who do not respond to this multidisciplinary management may

eventually have to be trained to use voice activated word processors etc.

F. Theories to explain diffuse WRULD and research

Various hypotheses have been put forward to explain symptoms of non-specific arm pain ofdiffuse WRULD. These include the suggestion that abnormal postures producing overuse ofone set of muscles and underuse of an opposing set, causes pain and tension in the muscles.In addition, certain positions of the limb increase pressure on or stretching of nerves. If bothchronic tension and direct mechanical compression occur together this can result in decreasedblood flow to the nerve producing scarring in and around it and leading to tethering and nervecompression.34

An alternative theory put forward by Fry in 1988, proposed that muscle overuse leads to adirect painful sequelae (resulting conditions) and changes to muscle fibres.35 He reported

33 “ABC of work related disorders” Mats Hagberg, Professor of work and environmental physiology at the NationalInstitute for Working Life, Solna, Sweden 17August 1996 British Medical Journal vol 313

34 “Repetitive motion injuries” Philip E Higgs et al Ann. Rev. Med. 1995, 46:1-1635 Dennet X, Fry HJH 1988 “Overuse syndrome: a muscle biopsy study” Lancet 1: 905-8


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changes in muscle biopsy specimens. However, others have suggested that when comparedto controls (ie “normal” specimens), these changes were not significant.36

Neurogenic theories suggest that nerves are sensitised by mechanical irritation and tractioncaused by overuse.37 The nerve becomes less tolerant of compression and stretching. Muscletenderness is explained on the basis of referred pain38 in the distribution of the sensitisednerves.

Since the non-specific WRULDs present with few physical signs, lack of objectivemeasurements is a major problem in achieving a diagnosis. Efforts have been directed toaddress this.

A research study reported in 199739 assessed heat changes in the hands in keyboard operatorssuffering from non-specific chronic forearm pain. The authors suggest that heatmeasurements could possibly be used as a diagnostic tool to evaluate non-specific arm pain,and to monitor progress during treatment. Although further work is needed in this field itoffers the exciting possibility of quantitative measurement of non-specific WRULD.

Another study (by Lynn and co-workers)40 measured vibration thresholds in sensory nervesrunning up the arm (median, ulnar and radial). Researchers found that keyboard operatorswho suffered diffuse arm pains, had raised vibration thresholds for the median and ulnarnerves, (which meant that they were less able to feel low intensity vibrations). The controlgroup of office workers had raised vibration thresholds only for the median nerve. Thepatient group felt more pain than the control group when their tolerance to vibration wastested by making the stimulus stronger. The authors say:

Patients with repetitive strain injury have objective signs of minor polyneuropathy,41 with themedian nerve being more severely affected than the ulnar nerve or radial nerve42.

36 “Occupational causes of disorders in the upper limb” N J Barton et al British Medical Journal vol 304, 1 February1992 p309-311

37 “Repetitive motion injuries” Philip E Higgs et al Ann. Rev. Med. 1995, 46:1-1638 Referred pain is felt at a site other than the injured part. Sensory nerves converge before they enter the brain,

causing confusion about the source of the pain signals.39 “Thermographic changes in keyboard operators with chronic forearm pain” SD Sharma et al. British Medical

Journal vol 314 11 January 199740 “Vibration sense in the upper limb in patients with RSI and a group of at-risk office workers” Dr Bruce Lynn etal

International archives of occupational and environmental health vol 71, p29-34 11 February 199841 disease involving all of the peripheral nerves in the area42 See footnote 39


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They are optimistic that the use of vibration testing, which is relatively inexpensive to carryout, may offer a simple way to monitor the progress of patients with non-specific WRULD.Dr Lynn accepts that more research is needed before a link between vibration loss and non-specific WRULD can be established. Furthermore, this was a small study and more work isneeded on a larger group of sufferers to establish causation and pin point areas of nervedamage.43 The Health and Safety Executive argues that a precise definition for RSI remainselusive.44

Current research in the ergonomic field being carried out by the Health and Safety Executiveincludes:45

• A study of musculoskeletal disorders among users of floor cleaning machines;• the development of a practical procedure to evaluate change in exposure to risk of

musculoskeletal disorders;• manual handling (weightload/frequency of lift)• guidance on manual handling in the construction industry through case studies• the discomfort associated with display screen equipment• a case-control study of osteoarthritis of the knee• the development of “tools” (procedures) to study the health effects of virtual

reality use

Planned projects for 1998/99 include:

• Review of the current medical management of Upper Limb Disorders• Investigation of muscle fatigue and biomarkers• Survey of user’s views on the acceptance, use and compliance of back support

belts

43 21 February 1998, British Medical Journal44 New Scientist 14 February 1998 “A call to arms”45 http://www.open.gov.uk/hse/mrm9899c.htm#1


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II Legislation and guidance

A. The Health and Safety at Work etc Act 1974

Historically, control of workplace health and safety in the UK was by means of industry-specific legislation. Following the Robens report46 in 1972 this approach was altered. Therecommendations of the report were implemented in the Health and Safety at Work etc Act1974 (cap 37) which created a more consensual approach towards occupational health andsafety laying down general duties applicable to all workplaces. This Act imposes a generalduty on "every employer to ensure, so far as is reasonably practicable, the health, safety andwelfare at work of all his employees". There are also general duties requiring employers andemployees to safeguard the health and safety of members of the public. It is arguable that ifthese provisions were applied to the letter of the law WRULDs would be prevented. The Act,however, allows for the introduction of secondary legislation in the form of specificregulations and codes of practice which aid this process. In particular recent regulationsstarting with the 'six-pack', which enact EC Directives, have placed a more explicit duty onemployers to assess and remove risks in the workplace.

B. The 'Six-Pack'

The Single European Act 198647 inserted Article 118A into the Treaty of Rome and thisallowed health and safety directives to be adopted by qualified majority voting. This led tothe introduction of a key health and safety measure commonly called the FrameworkDirective (89/391/EEC).48 It laid down general duties on employers and employees,analogous to the UK's Health and Safety at Work etc Act, for European countries that did nothave the benefit of such an all-embracing measure. In addition it required employers toassess risks at work to employees and others and to take steps to reduce and prevent them.

The Framework Directive and five daughter directives were adopted in the UK at the sametime, at the beginning of 1993, as a set of regulations usually referred to as the 'six-pack'.These are:

46 Report of the Committee on Safety and Health at Work Cmnd 5035 197247 implemented in UK by European Communities ( Amendment) Act 1986 cap5848 Note- There are other framework directives on different issues. Such directives establish general principles from

which further directives flow.


21

• The Management of Health and Safety at Work Regulations 1992 (SI 1992/2051)• The Manual Handling Operations Regulations 1992 (SI 1992/2793)• The Health and Safety (Display Screen Equipment) Regulations 1992 (SI

1992/2729)• The Provision and Use of Work Equipment Regulations 1992 (SI 1992/2932)• The Workplace (Health, Safety and Welfare) Regulations 1992 (SI 1992/3004)• The Personal Protective Equipment at Work Regulations 1992 (SI 1992/2966)

The key regulations are the Management of Health and Safety at Work Regulations thatimplement the Framework Directive. This and all of the five daughter regulations haveimplications for WRULD, but the most significant are the Health and Safety (Display ScreenEquipment) Regulations.

1. The Management of Health and Safety at Work Regulations (SI 1992/2051)

These are a new departure in the law, imposing a positive duty on employers to assess risks tohealth on the assumption that there may be risks even if there is no obvious evidence of any.It is the risk assessment that is the cornerstone of these regulations, and it is essential thatemployers understand this and carry it out successfully because everything else follows fromit.

There are a number of methods of carrying out risk assessments. One method, known as 'TheRule of TEN', provides an illustrative example of how such assessments can be applied toprevent WRULDs.49 This three-stage concept is equally applicable to the factory or office:

TARGET

Ô

EVALUATE Î THE RISK

Ò

NEGATE

49 Croner's Health and Safety Briefing No133, 29 Sept 1997, p4-5.


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Each stage is further sub-divided as follows:

A. TARGET B. EVALUATE C. NEGATEUnderstandingObservationsConsultations

PostureLay outsTask cyclesTask frequencyTask rotationsRest and recoveryWork organisationSuitability of employees

ErgonomiseRegulateMonitorEducateEncourageInvolveRespond

The regulations require employers to:

• Make a suitable and sufficient assessment of the risks to their employees' healthand safety and to identify measures to minimise them (reg 3);

• Make health and safety arrangements for the effective planning, organisation,control, monitoring and review of preventive and protective measures (reg 4);

• Provide appropriate health surveillance (reg5);• Appoint one or more competent persons to assist in carrying out their duties (reg

6);• Establish procedures to avert serious and imminent danger (reg 7);• Provide relevant information to employees (reg 8);• Provide health and safety training to employees both at recruitment and

subsequently if there are new or increased risks due to change of workresponsibilities, systems of work, new technology or equipment (reg 11).

2. Manual Handling Operations Regulations (SI 1992/2793)

Under these regulations manual handling means any transporting or supporting of a load,whether by lifting, putting down, pushing, pulling, carrying or moving it. These operationscan be carried out by hand or body force. Injury implies damage to any part of the body, notonly the back. Assessments should address the task, load, working environment andindividual capability.

All employers are required to:

• Avoid, where reasonably practicable, the need for employees to undertake anymanual handling operations involving risk of injury;

• Where avoidance is not reasonably practicable to:


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• Make a suitable and sufficient assessment of the manual handlingoperation to be undertaken;

• Reduce the risk of injury to the lowest level reasonably practicable;• Provide employees with general indications or, if possible, precise

information about the weight, heaviest side and centre of gravity of a load.(reg 4)

• All employees involved in manual handling operations must comply with thework system provided (reg 5).

3. Health and Safety (Display Screen Equipment) Regulations (SI 1992/2792)

The introduction of VDUs during the last decade has led to a range of health complaints byoperators. It is reported that one in three suffers from eye strain, back pain or lethargy, whileone in four complains of headaches.50 The incidence of visual discomfort depends uponoccupation. Symptoms include eye irritation, redness and soreness, temporary blurring andvisual confusion. Some people experience spots, shapes, chromatic halos around objects, andphotophobia (the dislike of lights). These often lead to headaches. Occasionally operatorsmay suffer from photogenic epilepsy.

There are a number of methods of combating visual fatigue, these include the use of a non-reflective, protective VDU glare filter screen; limiting the length of each session and theproportion of the working day devoted to VDU work; and location of the screen and optimumuse of window coverings to minimise glare.

Operators of VDU and associated equipment may also suffer from musculo-skeletal strainwhich presents itself as stiffness and tenderness on the neck, shoulders and forearms, and canlead to Repetitive Strain Injury (RSI) which is now termed work related upper limb disorder(WRULD).

The regulations require employers to:

• Assess, by making a suitable and sufficient analysis, the health and safety risks toall employees using a VDU workstation. These health risks are described asmusculo-skeletal and postural problems, visual problems, mental stress andfatigue. This is mandatory for all employees including home-workers, temporaryemployees (temps), and the self-employed (reg 2);

• Reduce the risks identified (reg 2);

50 Tolley's Health and Safety at Work Handbook 1998


24

• Review the risk assessment if there are major changes to hardware, software,workstation furniture, or relocation of the workstation, modification of lighting, orchanges to the VDU operators workload (reg 2);

• Ensure that workstations comply with the standards specified (reg 3);• Plan work so that VDU work is periodically interrupted by breaks or other work

so as to reduce the VDU workload (reg 4);• Provide employees with an initial eye/eyesight test, subsequent tests at regular

intervals, additional tests on request if employees are experiencing visualdifficulties, and corrective glasses where normal glasses cannot be used.Employees cannot, however, be forced to take tests (reg 5);

• Provide health and safety training in the initial use of the workstation andwhenever it is modified (reg 6);

• Provide health and safety information to enable employees to comply with regs 2-6 (reg 7).

The Health and Safety Executive has recently carried out a review of these regulations.51 Asa result of this it has issued a revised guidance booklet52 which includes advice on recentdevelopments such as the use of portable computers and work with a mouse.53 The HSE hasalso recently highlighted the problem of unsuitable posture at work which is often caused bypoor seating arrangements and is one of the main contributors to musculo-skeletal disorders.This was accompanied by the publication of revised guidance about seating at work54 whichaims to help employers assess suitable and safe seating, and seating design. It also includesexamples of good seating and workstation layout.55

4. Provision and use of Work Equipment Regulations (PUWER) (SI 1992/2932)

Under PUWER employers are required to provide suitable, safe, new or second-handequipment, maintain it correctly and inform operators of foreseeable dangers. The main aimof these regulations is to protect employees from dangerous machinery with parts that couldcause operator injury when properly used. Clearly such regulations are designed to cover awide range of equipment, with only some of the provisions of direct relevance to theprevention of WRULD. Of importance in the current context are the requirements onemployers to:

51 Evaluation of the Display Screen Equipment Regulations, HSE Contract research No 130/199752 Working with VDUs HSE 199853 HSE Press Release E017:97 5 Feb 9854 Seating at Work HSE 199855 HSE Press Release E25:98 16 Feb 98


25

• Select equipment having regard to the working conditions and any existinghazards on the premises, to the risks to health and safety of employees, and to anyadditional hazards posed by the equipment (reg 5);

• Ensure that equipment provided is constructed or adapted to be suitable for itspurpose (reg 5);

• Ensure that equipment provided is used only for operations and under conditionsfor which it is suitable (reg 5);

• Make available to all persons who use, or supervise the use of equipment, healthand safety information and instructions (reg 8), and training (reg 9) about theoperation of the equipment.

In guidance to the regulations the value of risk assessments made under the Management ofHealth and Safety at Work Regulations is emphasised as an aid to the choice of suitableequipment.

The requirements of the Amending Directive to the Use of Work Equipment Directive,95/63/EC must be implemented in the UK by 5 December 1998. To this end the Health andSafety Commission has published consultative documents containing proposals to amend theabove regulations on the use of work equipment generally, and the use of lifting equipmentand power presses in particular.56,57

5. The Workplace (Health, Safety and Welfare) Regulations (SI 1992/3004)

These regulations apply to all aspects of the workplace. Employers have duties to provideamongst other things

• A well maintained workplace (reg 5);• Adequate ventilation (reg 6);• A suitable temperature (reg 7);• Effective lighting (reg 8);• Sufficient space (reg 10);• Workstation and seating arrangements suitable to the person using them and for

the work that they do (reg 11);• Rest facilities that are suitable and sufficient (reg25).

56 Consultative Document 113, HSC, 1 June 199757 Consultative Document 116, HSC, 1 June 1997


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6. Personal Protective Equipment (PPE) at Work Regulations (SI 1992/2966)

These regulations control personal protective equipment (PPE) provided by employers. Theyare significant to risk of WRULDs because wearing PPE can alter an employees ability toperform tasks. Regulation 4 is the most relevant in this context. This requires employers toprovide suitable PPE when there is no other method of controlling health and safety risks.Suitable PPE is:

• Appropriate to the work involved;• Takes into account the health of the employee wearing it and his ergonomic

requirements;• Fits the employee;• Prevents the specific risk without increasing the overall risk.

7. Updating the 'Six-Pack' Regulations

The 'six-pack' regulations have been amended and added to subsequently by the following:

• The Management of Health and Safety at Work (Amendment) Regulations 1994 (SI1994/2865). This requires employers to minimise risks to pregnant, new and breast-feeding mothers;

• The Personal Protective Equipment (EC Directive) Regulations 1992 (SI 1992/3139),and the Personal Protective Equipment (EC Directive)(Amendment) Regulations1993, 1994&1996 (SIs 1993/3074, 1994/2326, and 1996/3039). These give details ofthe specification and enforcement of standards for personal protective equipment.


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III Compensation

Victims of industrial injury and disease may seek compensation through the civil courts forbreach of statutory duty and/or of the common law duty of care. In the majority of cases thelatter is used. In addition they may claim benefits which are paid under the social securitysystem. Compensation awarded by the courts depends upon the establishment of faultwhereas industrial injuries benefit is awarded without establishing fault and is referred to as'no-fault' compensation.

Personal damages awarded by a court to an employee against an employer are met by privateinsurance funded by the employer's liability insurance premiums. On the other hand socialsecurity payments are a form of public insurance which are funded by employers, employeesand taxpayers whether liability on the part of the employer can be established or not.

A. Fault versus No-Fault Compensation

There has been much controversy about the relative merits of fault and no-faultcompensation. A Royal Commission on Civil Liability and Compensation for PersonalInjury, chaired by Lord Pearson, reported in 1978.58 The appointment of the Commissionwas motivated in part by the legal expenses, delays and complexities that often occurredduring civil actions for compensation. In respect of industrial injuries, the PearsonCommission concluded that the (no-fault) industrial injuries scheme administered by whatwas then the DHSS should “provide the basis for improved provision for those injured atwork” and that the “conditions for compensation for occupational diseases should be lessrestrictive”. These increased compensation costs should be met, the Commission argued, byemployers. The Commission concluded that59 "Tort (civil wrong) should be retained forwork injuries as a means of supplementing the no-fault industrial injuries benefits", despitethe acknowledged criticisms.

Reform along the lines recommended has been slow despite the problems of the fault systemwhich may be summarised as follows:60

58 Cmnd 7054-I March 197859 para 93760 Tolley's Health and Safety Handbook 1998 p Int/40


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1. It lays too much emphasis on the behaviour of the defendant (i.e. culpability) rather than thesuffering of the plaintiff.

2. It is liability-oriented rather than accident-compensation oriented, and so adversarial.3. It is not related to the need of the plaintiff or to the defendant's ability to pay, but relies on

liability insurance.4. It aspires to deter the defendant from further acts of negligence, by imposition of damages;

imposition of 'penalties', however, is the hallmark of criminal law.5. Since social security benefits are payable almost immediately after injury at work whilst

personal injury damages are payable much later, the fault system would probably havecollapsed in the absence of a framework of compulsory liability insurance. However,structured settlements may eventually become the norm for accident victims, whereby theywould receive monthly payments.

In some countries, such as the Netherlands, the government has introduced a wide-ranging,national, no-fault compensation scheme. In the absence of this in the UK some trades unionshave negotiated individual schemes with employers. One example is the compensationagreement on keyboard and workstation-related upper limb disorders negotiated between thetaxworkers' union, PTC, and the Inland Revenue. This scheme covers clearly defined anddiffuse WRULDs resulting from VDU and keyboard activities including the use of a mouse.Such schemes have the advantages that compensation is paid quickly without the stress andcosts of legal proceedings. The disadvantages include lower payouts and reduced pressure onemployers to pay primary attention to prevention.

B. Breach of statutory duty

It is important to be aware that the remedies of Health and Safety at Work etc Act (HSWA)1974 are purely criminal and punitive and therefore not compensatory. Convictions under theAct do not of themselves give the right to compensation in a civil action for breach ofstatutory duty (Section 47(1) of HSWA) but they can be used as evidence of civil liability.Regulations made under the Act may, however, allow the injured person to seekcompensation in the civil courts for breach of statutory duty, unless this is specificallydisallowed in the relevant regulations (Section 47(2) of HSWA). The Management of Healthand Safety at Work Regulations 1992, is the only one of the 'six-pack' et seq to disallow this.Regulation 15 states:

'Breach of a duty imposed by these Regulations shall not confer a right in any civil proceedings'.

Although it is arguable that this restriction may be ineffective for, amongst otherconsiderations, it may be in breach of EC law because it could be considered as failure toimplement the Framework Directive in full.61


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C. Common Law Duty of Care

Additional to the legal responsibilities in statutes and their associated regulations, employersare subject to obligations imposed by the common law of tort (or civil wrongs). Commonlaw is a body of case law that comprises decisions made by judges about individual casesover the centuries. This has evolved, and is still evolving, based on custom and precedent.The common law duty of care in tort imposes a duty on employers to take reasonable care toprotect their employees from risk of foreseeable injury, disease or death at work. Most civilactions for compensation are brought under this. Breach of duty of care may give rise toliability in negligence (one of the branches of tort) for which compensation may be payable.

1. Individual cases

The TUC has reported62 that approximately 2000-2500 claims for WRULD compensation arepursued annually, but only a small number proceed to a court hearing. Many cases are settledout of court, some for large sums. These include awards to:63

PTC member Kathleen Tovey and Kathleen Harris, both typists at the Inland Revenue, who wereawarded £82,000 and £79,000 respectively, (and) to Kath Watson, giro processing machineoperator and CPSA member at the Benefits Agency, who was awarded £38,000 on the eve of thecourt hearing. UNISON won an out of court settlement of £60,000 for a council chainsawworker. USDAW achieved two settlements of over £30,000 for check-out operators in the north-east of England and MSF won £72,000 for an industrial radiographer in Scotland.

Of those awards that do reach court the cases most likely to succeed are those in which thereis a clearly diagnosed condition: cases of diffuse WRULD remain difficult to prove. Thiswas reflected in the pronouncement made by Judge Jon Prosser in the case of Mughal vReuters64 when litigation was in its infancy. He reportedly stated that keyboard operatorsforced to give up their jobs because of aching muscles and joints were "eggshell personalitieswho needed to get a grip on themselves". He added that their medical condition wasmeaningless and had "no place in the medical text book". Although this judgement wasconsidered by some experts to be anomalous, few cases of diffuse WRULD have succeededin court.

The following are examples of WRULD cases that have succeeded on the basis of commonlaw negligence. These include:65

61 Health and Safety: The New Legal Framework, Smith, Goddard and Randall, 1993, p2662 RSI Hazards Handbook, London Hazards Centre 199663 ibid64 Guardian , 29 Oct 93, Keyboard injury does not exist, judge rules65 Croner's Health and Safety at Work Special Report: Health and Safety Case Law Review, Issue 27 Feb 1997


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Ping V Esselte-Letraset (1992)

Nine employees of Esselte-Letraset worked in its factory at Ashford, Kent. Their work involvedgeneral tasks in the printing industry. All nine developed injuries including tenosynovitis, tenniselbow and trigger thumb, generally categorised as upper limb disorders. They claimed damagesfrom the company on the ground that their injuries had been caused by the repetitive movementsinvolved in their work.

The court's decision was as follows:

• the injuries had been caused by the work• the injuries had been foreseeable• there was a duty of care on behalf of the employers which could have been discharged by

giving a proper warning before the dangerous work had begun• the warning should include an explanation of the reason for, and importance of, reporting

any wrist or arm pain without delay• there should also be a regular educational process in relation to the risks• since there had been no adequate warnings, the employer was liable.

McSherry and Others v British Telecom (1993)

A county court award damages of £6000 to two British Telecom employees in respect of RSIcaused by keyboard work at high speed, using inappropriate furniture. British Telecom appealedagainst the judgement, but the matter was settled out of court on undisclosed terms, and theappeal was effectively abandoned.

This case in not a binding precedent, but it was the first of its type to come to court.

Mitchell V Atco (1995)

A motor tester employed by Atco, whose job involved much turning and twisting and lifting, wasdiagnosed as suffering from repetitive strain injury. Her claim for compensation succeeded onthe following grounds:

• the evidence of M's doctors should be accepted over that of the employer• Atco had known that the work carried out by the employee carried a foreseeable risk of

injury• the employer had given no advice on the risks and consequences of RSI• there had been no system of job rotation• the following compensation was awarded: £8500 for pain and injury, £27500 for loss of

earnings, and £6600 for future loss of earnings.

Hunter V Clyde Shaw plc (1995)

H worked as a radiographer for the defendants. His work involved moving castings, weighingup to five tonnes, on a turntable. He and his colleagues complained repeatedly about thedifficulty of the work, and H developed lateral epicondylitis (tennis elbow).

His claim for compensation succeeded: the Scottish court ruled that the employer had beennegligent in not taking all reasonable steps to provide him with safe equipment.


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The first WRULD common law case to be decided in the Court of Appeal took place in 1996.This was Pickford v ICI:66

The Court of Appeal ruled that a secretary who had developed writer's cramp could recoverdamages from her employers, because they had failed to supervise her work adequately, and hadnot provided information, warnings or instruction relating to the risks associated with the use ofdisplay screen equipment.

D. Social security benefits for prescribed diseases.

A disease is prescribed for social security purposes if there is a recognised risk to workers ina particular occupation and the link between disease and occupation can be reasonablypresumed or established in individual cases.67

The social security system assists people disabled through prescribed diseases, includingthose affecting the upper limbs,68 through three benefits. Industrial Injuries DisablementBenefit (IIDB) is payable to employed people disabled through a prescribed industrialdisease. It is not payable to the self-employed. Entitlement to IIDB depends upon medicalassessment of the degree of a person’s disability and, in general, it is paid only where aperson is assessed as more than 14% disabled. People who are assessed as disabled below thisthreshold can receive Reduced Earnings Allowance (REA) to meet the shortfall between theremuneration in their previous occupation and the remuneration available in any work whichthey remain able to do. At retirement age recipients of REA receive Retirement Allowance(RA) instead.

As the table below shows, few people in fact receive benefits in respect of a prescribeddisease of the upper limbs. At April 1997, around 22,000 people were receiving one of thesebenefits.

66 ibid67 Cm 1936, “Report on Work Related Upper Limb Disorders” Industrial Injuries Advisory Council, 199268 see Appendix 1 for conditions of prescription and list of prescribed diseases


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Benefits in payment to persons affected by upper limb disordersGreat Britain (a), April 1997

Industrial Injuries

Disablement Benefit

Reduced Earnings

AllowanceRetirement Allowance Total

Cramp of the hand or forearm 419 105 23 547Beat hand 20 12 - 32Beat elbow 53 - - 53Synovial inflammation (tendonitis) 2,521 1,449 304 4,274Vibration white finger 4,722 8,318 3306 16,346Carpal tunnel syndrome 602 187 23 812

Total 8,337 10,071 3,656 22,064

a) Including some cases payable overseas.

Source: DSS IIDB/REA Statistics 1996/97

1. Industrial Injuries Advisory Council Review

The Industrial Injuries Advisory Council (IIAC) is an independent statutory body set upin 1946 to advise the Secretary of State for Social Security on matters related to theIIDB, and is responsible for designation of prescribed diseases. IIAC has undertakendetailed reviews of a number of WRULDs eg rotator cuff syndrome69 and has foundthat, in spite of a large volume of anecdotal evidence, there is insufficientepidemiological evidence to support their prescription. A review of WRULDs in 1992added only carpal tunnel syndrome in relation to hand-held vibrating tools to the list.However, it considered that many other cases of carpal tunnel syndrome areoccupationally caused, and recommended that the condition of carpal tunnel syndromealone be prescribed on an individual basis where relevant work place exposure at theappropriate time can be demonstrated.70

This system of individual proof is becoming more common and has been applied tooccupational asthma and chronic bronchitis and emphysema in coal miners workingunderground for 20 years.

69 Rotator cuff syndrome results from inflammation, tears or rupture of the tendons of the muscles that rotate theshoulder joint

70 Cm 1936, “Report on Work Related Upper Limb Disorders” Industrial Injuries Advisory Council, 1992


33

IIAC is currently undertaking a further comprehensive review of the list of occupations forwhich IIDB is paid, both in relation to examining the links between specific occupations anddiseases, and in order to simplify the structure of the scheme. IIAC started taking evidence inOctober 1997, but there is as yet no date for completion of the review.71

2. Compensation Recovery Scheme

In 1990 a compensation recovery scheme72 was introduced which required that benefits mustbe paid back in full by the claimant if a civil compensation award of more than £2,500 wasawarded. (Below this figure no recovery took place). The effect was that many claimants hadto pass on the total amount of any settlement to the DSS.

This scheme has now been modified with the result that after 6 October 199773 the smallpayments limit of £2,500 has been removed and the responsibility for paying back benefitswill fall to the compensator. That element of the compensation award for pain and sufferingwill be payable in full to the claimant. Compensation for loss of earnings will be paid by thecompensator to the DSS to repay benefit, and that in excess of social security payments willbe paid to the litigant.

71 IIAC spokesman 17 March 199872 Social Security Administration Act 199273 Social Security (Recovery of Benefits) Act 1997


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IV Appendix 1

Section 76(2) of the Social Security Act 1975 sets out the conditions that must be satisfiedbefore a disease is prescribed.

“A disease or injury may be prescribed in relation to any employed earners if the Secretary ofState is satisfied that:

(a) it ought to be treated, having regard to its causes and incidence and any other relevantconsiderations, as a risk of their occupations and not as a risk common to all persons;and

(b) it is such that, in the absence of special circumstances, the attribution of particularcases to the nature of the employment can be established or presumed with reasonablecertainty”.

In other words, a disease can only be prescribed if there is a recognised risk to workers in acertain occupation and the link between disease and occupation can be reasonably presumedor established in individual cases.74

Under the Social Security (Industrial Injuries) (Prescribed diseases) Regulations 1985 (SI1985 No. 967) as amended the following WRULDs are prescribed occupational diseases:

Disease number Prescribed disease or injury Any occupation involving

A4 Cramp of the hand or forearmdue to repetitive movements.For example, writer’s cramp

Prolonged periods of handwriting,typing or other repetitive movementsof the fingers, hand or arm.For example, typists, clerks androutine assemblers.

A5 Subcutaneous cellulitis of thehand (Beat hand)

Manual labour causing severe orprolonged friction or pressure on thehand.For example, miners and roadworkers using picks and shovels.

A7 Bursitis or subcutaneouscellulitis arising at or about theelbow due to severe orprolonged external friction orpressure at or about the elbow(Beat elbow)

Manual labour causing severe orprolonged external friction orpressure at or about the elbow.For example, jobs involvingcontinuous rubbing or pressure onthe elbow.

74 Cm 1936, “Report on Work Related Upper Limb Disorders” Industrial Injuries Advisory Council, 1992


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Disease number Prescribed disease or injury Any occupation involvingA8 Traumatic inflammation of the

tendons of the hand or forearm,or of the associated tendonsheaths (Tenosynovitis)

Manual labour, or frequent orrepeated movements of the hand orwrist.For example, routine assemblyworkers.

A11 Episodic blanching, occurringthroughout the year, affectingthe middle ear or proximalphalanges or in the case of athumb the proximal phalanx, of(a) in the case of a person with

5 fingers (including thumb)on one hand, any 3 of thosefingers, or

(b) in the case of a person withonly 4 such fingers, any 2of those fingers, or

(c) in the case of a person withless than 4 fingers, any oneof those fingers or, as thecase may be, the oneremaining finger (vibrationwhite finger)

(a) The use of hand-held chain sawsin forestry; or

(b) The use of hand-held rotary toolsin grinding or polishing of metal,or the holding of material beingground, or metal being sanded orpolished by rotary tools; or

(c) The use of percussive metal-working tools, or the holding ofmetal being worked on bypercussive tools, in riveting,caulking, chipping, hammering,fettling or swaging; or

(d) The use of hand-held poweredpercussive drills or hand-heldpowered percussive hammers inmining, quarrying, demolition, oron roads or footpaths, includingroad construction; or

(e) The holding of material beingworked upon by poundingmachines in shoe manufacture.

A12 Carpal tunnel syndrome Use of hand-held vibrating toolswhose internal parts vibrate so as totransmit that vibration to the hand,but excluding those which are solelypowered by hand

Documents

Work Related Upper Limb Disorders€¦ · Work Related Upper Limb Disorders A rising tide of litigation has highlighted a growing problem of work related upper limb disorders (WRULDs),